Ventura County

Air Pollution
Control District
3433 Roberto Court, San Luis Obispo, CA 93401
TEL: (805) 781-5912 FAX: (805) 781-1002
Email: info@slocleanair.org
Web Site: www.slocleanair.org

260 N. San Antonio Road, Suite A
Santa Barbara, CA 93110-1315
TEL: (805) 961-8800 FAX: (805) 961-8801
Email: engr@sbcapcd.org
Web Site: www.sbcapcd.org
669 County Square Drive, Ventura CA 93003
TEL: (805) 645-1401 FAX: (805) 645-1444
Email: engineering@vcapcd.org
Web Site: www.vcapcd.org


AGRICULTURAL ENGINE REGISTRATION APPLICATION FORM

(CONTINUED ON NEXT PAGE)
(District Use Only)
Date Received Stamp APCD Application
Number: Registration No. Fee:
Receipt No. Check No.
Comments


Form AG-1 Page 1 of 5 July 2014
(Application must be typewritten, computer generated, or hand printed in ink. Complete all pages of the application.)
IMPORTANT: To assure that your application is complete include all of the following when submitting this application:
Registration Fee Complete all sections Signature on Application One Engine per Application

San Luis Obispo APCD: $210 Santa Barbara APCD: $229 Ventura APCD: $200
This application form is for the registration of existing and new stationary and portable diesel engines rated greater than or
equal to 50 bhp that are used in Agricultural Operations. To the extent allowed by law, the engine registered in this
application may be operated in San Luis Obispo, Santa Barbara or Ventura Counties. The registration will denote any
geographic operational restrictions. You do not need to register diesel engines used to power agricultural wind machines or
engines that provide motive power (i.e., motor vehicles, tractors). You are required to register the engine in the County that
the engine resides. See Form AG-2 for instructions and common definitions of the terms used in this application and the
Airborne Toxic Control Measure. Submit this application to the District in which the engine resides.
1. Facility Name:
Facility Street Address
Assessor Parcel Number(s) (APN)

City, State ZIP:

2. ENGINE OWNER: (If a rental unit, fill in the rental companys information here.) Is this a Rental Unit? Yes No
Contact Person:

Work Phone:

Company Name:

FAX:

Mailing Address:

Cell Phone:

City, State ZIP:


E-Mail:
3. OTHER CONTACTS: (Are the contacts below the same as Engine Owner? If not, complete Section 16 also)
Operator: Same as Owner
Billing: Same as Owner
Inspections: Same as Owner
Correspondence: Same as Owner
4. AUTHORIZED AGENT: Is this application filled out by an Authorized Agent? Yes No
If Yes, fill in Section 17.
5. PURPOSE OF APPLICATION: (check all that apply)
New Engine Existing In-Use Engine Install Emission Controls Replace Existing Engine
Other (describe):



Ventura County
Air Pollution
Control District

AGRICULTURAL ENGINE REGISTRATION APPLICATION FORM (Continued)

Form AG-1 Page 2 of 5 July 2014
6. DISTRICT : (Check the Counties where this engine currently resides and/or may operate in the future)
San Luis Obispo County Santa Barbara County Ventura County
7. ENGINE USE:
Water Well Pump Booster Pump Electrical Power Irrigation Pump
Other (describe):
8. ENGINE CLASSIFICATION: (Check one. See the definitions Form AG-2 for clarification)
Stationary Seasonal Portable (note: booster and well pumps are considered stationary for this ATCM)
If portable, describe how this was determined:
9. ENGINE DATA: (Enclose a copy of the engine data sheet and a photo of the engine nameplate, if available)
Installation Date: Manufacture Date or Approximate Engine Age:
Make: Model: Serial No:
Maximum Rated Brake Horsepower: bhp EPA Engine Tier: (options: Tier 0, 1, 2, 3 or 4)
Fuel Used: CARB Diesel Other (describe): Operator ID:

Estimated Average Fuel Use: gallons per year

(Provide the following if known)
EPA Family Name:
Average Operating Hours: hours per year

(Provide the following if known)
ARB Executive Order No:
10. STANDBY ELECTRICAL GENERATORS: (Provide this generator data in addition to the engine data above)
Generator Mfgr: Model: Rating: kW
Is the generator only used during emergencies as defined in the ATCM?
Yes No
Is the engine equipped with a non-resettable hour meter with minimum display of 9,999 hours?
Yes No
Is the generator enrolled in an electrical utility Interruptible Service Contract (ISC)?
Yes No
If part of an ISC program, does the contract require the engine to be used during Stage II/III alerts?
Yes No
11. REMOTE ENGINE EXEMPTION:
Are you claiming the remote engine exemption? (note: only applies to Existing In-Use engines) Yes No
Will this engine ever be used in Ventura County? Yes No
Is the engine located more than one-half mile from any residential area, school, or hospital? Yes No
12. NEW ENGINES: (fill in for all engines installed after January 1, 2005)
Date of engine purchase:
EPA Family Name:








Ventura County
Air Pollution
Control District

AGRICULTURAL ENGINE REGISTRATION APPLICATION FORM (Continued)

Form AG-1 Page 3 of 5 July 2014

13. ENGINE LOCATION
ENGINE GEOGRAPHIC COORDINATES. Provide the exact point where the engine is located. This data can be obtained by
many methods including: handheld GPS, cell phone enabled GPS, using free online tools such as Google Earth.
Geographic Coordinates: and (circle the units): Lat/Long, UTM
If UTM Coordinates are used, circle the reference Datum: NAD27, NAD83, WGS84

If available, provide a map or aerial/satellite picture showing the entire property. Use a pen or
marker to outline the property boundary and the location of the engine. Such maps/pictures may
be obtained using Google Earth, Google Maps, Yahoo Maps, the Farm Works Farm Trac
software or a similar type of package. Are such maps/pictures enclosed?


Yes No
Does the engine ever change location at this farm?

Yes No
Is the engine located within one-quarter mile of (1,320 feet) of a residential area, school, or
hospital? (include engines that may change location from outside 1,320 feet as identified in the
answer above). If Yes, answer the following two questions:
Yes No
(a) Distance from the engine to the residential area, school or hospital = feet
(b) Direction from the engine to the residential area, school or hospital = (e.g. NE)

14. EMISSION CONTROLS: (Please complete this section if emission controls are proposed or are on the engine)
Diesel Particulate Filter Oxidation Catalyst Other (describe):
Make: Model: ARB Executive Order No:
Particulate Matter Reduction Efficiency: % (by mass)

15. SIGNATURE:
I hereby certify that all information provided on this application, and any attachments, is true and correct. I agree to pay
any and all fees required by District rules for processing this application and for issuance of any Registration. If I
abandon this project and withdraw my application, or should my application be disapproved, I understand that the
registration fee is not refundable.

SIGNATURE: DATE:

PRINT NAME:

ORGANIZATION:










Ventura County
Air Pollution
Control District

AGRICULTURAL ENGINE REGISTRATION APPLICATION FORM (Continued)

Form AG-1 Page 4 of 5 July 2014
16. ADDITIONAL CONTACTS:


Use this Section to add the contact information associated with your registration application. The registration holder/owner is assumed to
be the contact in all of the below categories unless the District is otherwise informed. You may provide additional contact information,
such as cell phones, FAX numbers, or email, as you desire.

OPERATOR
Contact Person Work Phone:
Company Name FAX:
Address Cell Phone:
City, State, Zip:
Email::



BILLING
Contact Person Work Phone:
Company Name FAX:
Address Cell Phone:
City, State, Zip:
Email:

CORRESPONDENCE
Contact Person Work Phone:
Company Name FAX:
Address Cell Phone:
City, State, Zip:
Email

INSPECTION / OTHER
Contact Person Work Phone:
Company Name FAX:
Address Cell Phone:
City, State, Zip:
Email:

STATE THE NATURE OF
THIS CONTACT:
(e.g.: inspection contact)














Ventura County
Air Pollution
Control District

AGRICULTURAL ENGINE REGISTRATION APPLICATION FORM (Continued)

Form AG-1 Page 5 of 5 July 2014
17. AUTHORIZED AGENT: (Complete this Section if appropriate)

I hereby designate
(agents name- print)

of
(agents business name - print)

to serve as the Authorized Agent for my company:


(applicant companys name - print)

at
(facility name(s) - print)

in dealing with either the San Luis Obispo County APCD, Santa Barbara County APCD or Ventura
County APCD in matters regarding (check as appropriate):

Engine Registration Application Billing
Air Toxics/HRA Source Testing
Inspections and compliance All of the above
Other (state purpose):

This Designation includes written correspondence, telephone discussions and meetings and shall
remain in effect until it is suspended in writing by my company or the following
date: whichever is earlier.

As a designated Responsible Official, I hereby authorize the above mentioned agent to represent my
company in the matters identified above:

Name (print)
Title
Phone
Address
City, State, ZIP
Signature